Florida legislature advances bills to curb comanagement

The medical association and ophthalmology society here are backing new legislation to restrict comanagement in the state.

TALLAHASSEE, Fla. — Surgeons in Florida may be increasingly responsible for the postoperative care of their patients if bills currently before the Florida House and Senate are passed.

House Bill 553 and Senate Bill 924 would authorize only medical doctors licensed under chapters 458 and 459 of the Florida statutes to provide postoperative ocular care. Those chapters pertain to medical doctors and doctors of osteopathic medicine only.

The Florida legislation would allow only MDs to provide post-operative ocular care.

The bills under consideration by the Florida legislature have the backing of the American Medical Association, the Florida Medical Association (FMA), the Florida Society of Ophthalmology (FSO), the Florida College of Emergency Physicians (FCEP), the American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS).

MDs must be responsible

The FMA has written an issue paper to advise physicians and surgeons about the legislation.

"In all surgical specialties, with the exception of ophthalmology, the surgeon has full responsibility for the patient," the issue paper states. "In recent years non-medical doctors have been increasingly engaged in co-managing ocular surgical care."

The FMA's paper states that legislation is needed to protect the public from untrained health providers. According to the FMA document, "It is important that when surgery on the eye is required, the most highly trained specialists are available. In many cases optometrists are provid- ing post-operative ocular care. Optometrists have no surgical training, are prohibited from doing any type of surgery and are only allowed to prescribe eye drops. Optometrists are not allowed, because they do not have the training, to prescribe systemic drugs or diagnose diseases of the body, all requirements to oversee patients after surgery."

The FMA also points out that most complications occur after surgery. The FMA document states that it is exceedingly rare for vision threatening complications to transpire intraoperatively. More than 90% of all complications from eye surgery that blind an eye or significantly reduce vision occur 2 to 10 days after the surgery is completed, it says; therefore, speed of diagnosing complications and initiating surgical remedy is vital.

"The shorter the duration of a patient's onset of signs/symptoms to surgical intervention, the higher percent chance of favorable outcome. Disaster results when a carpetbagger surgeon hundreds of miles away, and an optometrist, cannot accurately diagnose or treat this emergency," states the issue paper.

The position paper also claims optometrists are advertising surgeries they are not allowed to perform.

"Optometrists aggressively advertise to non-patients to come in for free LASIK evaluation or free cataract evaluation, even though they cannot perform the surgery. Commonly large outdoor billboards advertise the free evaluations despite numerous ophthalmology practices in the neighborhood. Optometrists lure interested potential patients so that they can then act as bounty hunters referring the newly captured patients to the highest bidder ($600 per eye for LASIK)," the position paper states.

As with most position papers and recent legislation on the issue, the FMA also points to the inappropriate practice of using postoperative care as an inducement for referral fees. The FMA cites the February 2000 AAO/ASCRS paper, which states in part, "If the reason for sharing postoperative care with another provider is economic, specifically as an inducement for surgical referrals, or the result of coercion by the referring practitioner, it is patently unethical and in many jurisdictions, illegal."

Penalties

HB 553 and SB924 state that when the Florida board of medicine finds any person guilty on any of the grounds of comanagement it may enter an order imposing one or more of the following penalties: refusal to certify, or certification with restrictions, of an application for licensure, certification or registration; revocation or suspension of a license; restriction of practice; imposition of an administrative fine not to exceed $10,000 for each count or separate offense; issuance of a reprimand; placement of the physician on probation subject to conditions including requiring the physician to submit to treatment, to attend continuing education courses, to submit to re-examination or to work under the supervision of another physician; issuance of a letter of concern; corrective action; refund of fees billed to and collected from the patient; or imposition of an administrative fine in accordance with current statutes for violations regarding patient rights.

MDs need the law

In an open letter to Florida ophthalmologists, FSO president Mark Michels, MD, urges MDs to support the legislation.

"There has been a great deal of misinformation regarding these bills by organized optometry, which routinely opposes anything that the FSO supports. My goal in writing this letter is to set the record straight with our members and other Florida ophthalmologists so that we can respond appropriately to requests to oppose the bill when asked to do so by optometrists with whom we work," said the letter.

Dr. Michels also pointed out that the bills provide for potential disciplinary action by the Board of Med- icine for physicians and osteopaths who "delegate ocular post-operative responsibilities to a person not licensed under chapter 458 or chapter 459."

According to Dr. Michels, the legislation is nothing new.

"Almost 10 years ago, the Florida Board of Medicine promulgated the Florida Surgical Care Rule clearly indicating that 'the ultimate responsibility for diagnosing medical and surgical problems is that of the licensed doctor of medicine or osteopathy who performed the surgery. Management of post-operative care of any surgical patient is the responsibility of the operating surgeon.'"

The rule authorized the operating surgeon to delegate discretionary postoperative activities to equivalently trained MDs and osteopaths, but prohibited the delegation of postoperative care to other non-MD health care practitioners, unless those health care practitioners are properly supervised. Despite legal challenges by optometry in court, both an administrative law judge and an appellate court upheld the rule as valid.

Dr. Michels also noted that requests for regulation of comanagement were coming from an unusual source: emergency room physicians.

"The Florida College of Emergency Physicians has complained increasingly about post-operative eye patients coming to their local ERs unable to locate their operating surgeon (or the optometrist) who is co-managing," said Dr. Michels.

He explained that ER on-staff and on-call ophthalmologists are reluctant to take on a postoperative problem if they have not previously treated the patient. "ER physicians are spending a lot of time with the difficult treatment of these patients," the letter said. "This contributes to backlog in the ER, thereby depriving other patients of prompt emergency medical care. The FSO also has received several letters from members complaining that they are having to diagnose and treat for the first time patients who are clearly the responsibility of the operating surgeon."

Melanie S. Boscan, legislative liaison for the FMA, said that HB 553 has passed through the House Health Regulation committee and SB 924 passed out of the Senate Health, Aging and Long-Term Care and Senate Banking and Insurance committees.

"The FMA strongly supports this legislation that would ensure patients who have eye surgery will be seen by the surgeon or an equivalently trained medical doctor post-operatively, to make sure that no sight-threatening complications occur after surgery. This is a quality of care issue that protects the patients of Florida," said Ms. Boscan.

Optometry and managed care respond

The Florida state legislature offers committee analysis for state representatives to research prior to voting on a bill. The House Health Regulation Committee Analysis of HB 533 included comments from the Florida Optometric Association, Aetna US Healthcare, and the vice chair of the Florida Board of Optometry.

The Florida Optometric Association commented that, "Optometrists have been providing post-operative care for decades without harm to their patients. The bill permits MDs and DOs to provide ocular postop care irrespective of their specialty or training. This means that MDs and DOs who have very little training and experience in eye health care could provide post-operative care while optometrists who have extensive and specialized education, training, and experience could not provide eye health care merely because they are ODs and not licensed under Chapters 458 or 459."

A representative of Aetna US Healthcare, CIGNA and Humana Inc. provided a statement indicating that "ophthalmologists frequently use physician assistants, nurses and optometrists under their supervision to assist with post ocular surgery care which is permitted by the Board of Medicine rules governing the practice of medicine. My health plans have no evidence or complaints from their insureds that the utilization of these practitioners has resulted in quality of care problems. The utilization of only medical doctors for post ocular care will obviously substantially increase the cost of surgery without evidence that such will result in a corresponding improvement in the quality of care."

The vice chair of the Board of Optometry pointed out that "Nova Southeastern University's fourth year optometry students spend at least one clinical rotation (3 months) in a co-management center."

For Your Information:

• Mark Michels, MD, can be reached at 3399 PGA Blvd., Ste. 220, Palm Beach Gardens, FL 33410; (561) 624-0099; fax: (561) 624-7373; FSO Web site: www.medeye.org.

• Melanie S. Boscan can be reached at 113 East College Ave., P.O. Box 10269, Tallahassee, FL 32302; (850) 224-6496; fax: (850) 222-8030; e-mail: mboscan@medone.org; Web site: www. medone.com.